Fax: 1604 325 1414
info@hudinsurance.com
HABITIONAL INSURANCE APPLICATION
Application must be fully completed and accompanied by Rebuilding calculator and original photographs
Policy Number:
Replacing Policy Number:
Broker Name:
Broker City:
Phone:
Fax:
Principal Residence
Tenant’s Package
Secondary Residence
Name of Insured
Seasonal Residence
Condo Package
Telephone No
Postal Address
BROKER REPORT:
Occupation
Years of Continuously Employed
Date of Birth
Applicant
Co-appli ant
Previous Insurer
Policy Number
Has any Company Refused, Cancelled, Declined to Renew Applicant?
Yes
N
If yes, give details
PREVIOUS CLAIM IN LAST 5 (five) YEARS:
Date of Loss
(mm/dd/yy)
Full Details of Loss
Amount Paid or reserved
How long has Applicant lived at this location?
Is there any Commercial Exposure on the premises?
Yes
No
Yes
No
If yes, describe
If a tenant above a restaurant, is there an approved C02 system?
HABITIONAL INSURANCE APPLICATION 16-03-06
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Is Client financially acceptable to your office?
Have you personally seen this property?
Yes
Yes
No
No
Condition of Property
Is there any Knob & Tube or Aluminum wiring in the dwelling?
Is Property for Sale?
Yes
No
Yes
Good
Fair
Poor
No
If yes, please provide details
LOCATION #1:
Year Dwelling Built
Legal Address
Postal Code
LOSS PAYABLE:
(Incl. FULL mailing address)
Amount owing on ALL mortgages
OCCUPANCY:
Primary
Secondary
Vacant
$
Seasonal
Under Construction
CONSTRUCTION:
Frame
STRUCTURE TYPE:
Unoccupied
Other (describe):
Brick Veneer
Detached
Multi-Plex
Units
HEATING:
Rental
Masonry
Semi-Detached
Apt. Bldg - # of
Fuel
Fire Resistive
Townhouse
Row house
Duplex
Triplex
Mercantile - Describe
Primary
Auxiliary
UPDATES
Furnace (Central)
Combination with Wood
Electric
Space Heater
Fireplace Insert
Solid Fuel Heating Unit
Furnace (central) with add
on wood burning unit
Full
Partial Year
Electric # of amps
Heating
Plumbing
Roof
If updates are Partial, describe:
A Woodstove Questionnaire must accompany application
OIL TANK:
Inside
Outside
Above Ground
In Ground
Age:
An oil tank questionnaire must accompany application
PROTECTION GRADE:
ALARMS:
Within 300 m of Hydrant
Burglary
Optional Coverages:
Central
Sewer Backup
DETACHED STRUCTURE:
Local
Within 8 km of Fire hall
Fire
Mass Evacuation
Yr Built
Heat
HABITIONAL INSURANCE APPLICATION 16-03-06
Size
Use
Central
Local
Earthquake
Unprotected
Low Temp.
Central
Local
Lock Replacement
Construction
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Dwelling
Building
$
Detached
Private
Structures
Personal
property
$
LIMITS REQUIRED
Additional Living Legal Liability
Expenses
$
$
Voluntary
Medical
Payments
$1,000
$1,000,000
Voluntary
Property
Damage
$250
LOCATION #2:
Year Dwelling Built
Legal Address
Postal Code
LOSS PAYABLE:
(Incl. FULL mailing address)
Amount owing on ALL mortgages
$
OCCUPANCY:
Primary
Secondary
Seasonal
Vacant
Under Construction
CONSTRUCTION:
Frame
STRUCTURE TYPE:
Brick Veneer
Detached
Multi-Plex
Units
HEATING
Rental
Unoccupied
Other (describe):
Masonry
Semi-Detached
Apt. Bldg - # of
Fuel
Fire Resistive
Townhouse
Row house
Duplex
Triplex
Mercantile - Describe
Primary
Auxiliary
UPDATES
Furnace (Central)
Combination with Wood
Electric
Space Heater
Fireplace Insert
Solid Fuel Heating Unit
Furnace (central) with add
on wood burning unit
Full
Partial Year
Electric # of amps
Heating
Plumbing
Roof
If updates are Partial, describe:
A Woodstove Questionnaire must accompany application
OIL TANK:
Inside
Outside
Above Ground
In Ground
Age:
An oil tank questionnaire must accompany application
PROTECTION GRADE:
ALARMS:
Within 300 m of Hydrant
Burglary
Optional Coverages:
Central
Sewer Backup
DETACHED STRUCTURE:
Local
Within 8 km of Fire hall
Fire
Mass Evacuation
Yr Built
Size
Heat
Use
HABITIONAL INSURANCE APPLICATION 16-03-06
Central
Local
Earthquake
Unprotected
Low Temp.
Central
Local
Lock Replacement
Construction
Page 3 of 5
Dwelling
Building
$
Detached
Private
Structures
$
Personal
property
LIMITS REQUIRED
Additional Living Legal Liability
Expenses
$
$
Voluntary
Medical
Payments
$1,000
$1,000,000
Voluntary
Property
Damage
$250
SCHEDULED ARTICLES (Personal Articles, Fine Arts, Watercraft)
Personal Articles/Fine Arts (Appraisal required on articles valued in excess of $1,000
A Deductible may apply
ITEM #
DESCRIPTION OF ARTICLES
AMOUNT OF INSURANCE
Yes
Is Jewelry kept in Vault?
Is Rental Income Required?
If yes, for what limit?
No
If yes, what limit is in vault?
Yes
No
$
$
EXPOSURE INFORMATION:
Explain ‘Yes’ Responses in Remarks
Yes
No
Additional Residences/Properties
Location Rented to others
# Weeks:
More than one family in the dwelling
Rooms rented to others
# of Units:
Daycare
# of Children:
Incidental Office Use
Commercial Operations at this location
Swimming Pool
Saddle / Draft Animals
#:
Voluntary Compensation Required?
More than 10 Acres
Servants: In:
Out
Chauffeur
Other Exposures:
Remarks (‘Yes’ Responses MUST be explained):
Occasional
ADDITIONAL INFORMATION REQUIRED FOR SEASONAL/SECONDARY RESIDENCES:
How many weeks is the residence occupied and unoccupied?
When not occupied, who takes care of the premises?
Is there a full time caretaker?
Is there a part time caretaker?
What is the frequency of visits?
Yes
Yes
No
No
What other components does the alarm have? (such as water detector, low temperature, back up cellular, etc)
NOTES:
HABITIONAL INSURANCE APPLICATION 16-03-06
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Consumer and previous insurer reports containing personal, credit, factual or investigative information may be
sought in connection with this application for insurance or a renewal, extension or variation of the insurance
applied for.
I hereby make application for insurance on the above charges items of property, subject to the Statutory
Conditions, Stipulations Warranties, Exclusions, Limitations, Conditions, and Definitions as contained in the
policy or endorsed thereon. THE STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND CORRECT.
Date:
Signature of Applicant:
Date:
Signature of Broker:
SUBMITTED BY:
E-MAIL:
HABITIONAL INSURANCE APPLICATION 16-03-06
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